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14.Murmur: both components of S2 (aortic A2, pulmonic P2) are heard at the apex,
implying an increased of S2
Origin: apex
Possible associated diagnosis: ASD, pulmonary hypertension. (Carabello et al,
2006).
Pitch: Low
Intensity: 1-3/6
Location: LUSB
Character: Blowing
Intensity: 1-3/6
Pitch: Medium
Character: Blowing
Helpful Maneuvers: None
Intensity: 1-3/6
Pitch: Medium
Character: Machinery-like
When to Refer?
When these criteria are not met
When patient or family persists in belief of disease
Assess anxiety level of family and patient
Small VSD (23%)
High-pitched Holosystolic murmur @ LMSB to LLSB
May or may not have a thrill
Generally no LV heave or RV lift
Normal S2
No diastolic murmur
Normal EKG and chest x-ray
Small VSD
Most common form of CHD
75-90% close by 1 year of age
Incidence is inversely correlated to newborns age
No SBE Prophylaxis
Pulmonary Stenosis (14%)
Systolic Ejection Murmur @ LUSB with radiation to back
May have systolic thrill
May have increased RV impulse
Usually with ejection click
May have RVH on EKG
May have prominent MPA on X-ray
Pulmonary Stenosis
Often confused w/ innocent pulmonary flow murmur or ASD
Systolic gradient across valve >25mmHG
Mildly thickened valve in a neonate can resolve with time
No SBE prophylaxis
Aortic Stenosis (13%)
Systolic ejection murmur @ RUSB to Neck
May have thrill @ RUSB or SSN
Usually with ejection click
May have LV heave
May have assoc diastolic murmur if valve leaks
May have LVH on EKG
May have cardiomegaly, or prominent aortic shadow on x-ray
Aortic Stenosis
Easy to diagnose when moderate to severe
Bicuspid Aortic Valve
1% of population??
Can be asymptomatic
Late complications
Stenosis or Insufficiency
No SBE prophylaxis
Large VSD (8%)
Low pitched Holosystolic murmur @ LMSB to LLSB
Diastolic flow rumble @ apex
Increased precordial activity
Increased P2 intensity
May have RVH +/- LVH on EKG
May have cardiomegaly and pulmonary plethora on x-ray
Large VSD
Perimembranous or membranous
can also be muscular
Pulmonary overcirculation
LA/LV enlargement
The first heart sound (S1) is associated with closure of the mitral and tricuspid valves. It
is best heard at the apex or the left lower sternal border. Occasionally, an ejection
click may closely follow S1, sounding like a split. This is most audible at the upper
sternal borders, and is normal. The second heart sound (S2) is associated with closure
of the aortic and pulmonic valves. It is best heard at the left upper sternal border. The
first component of a normal S2 is A2 (aortic), followed by P2 (pulmonic). A2 is
louder than P2. The spacing between these two sounds can vary with respiration
(increasing with inspiration and decreasing with expiration). S3 is a low-frequency
sound that can be heard in early diastole, and is associated with rapid ventricular
filling. S4 is heard in late diastole and is associated with decreased ventricular
compliance or congestive heart failure – it is always pathologic.
9. Abnormal heart sounds other than the murmur Common innocent murmurs: